John Myseros

112 statements · 2 topics

Featured statements

▶ Ep 43 · 2:53
The reason we think that happens incidentally is because it gets so taut, it gets so Distorted from being pulled on that the little micro vessels, particularly the little arterials in the end of the cord, get occluded and, or at least get stenosed, and there is local ischemia and an ischemic cord leads to nonfunctioning nerve roots, particularly the lower sacral nerve roots which go to the bowel and bladder are super sensitive to this.
quote · Anorectal Malformation
▶ Ep 43 · 13:36
So that's our tendency is to untether them, untether them when they're babies, because there's evidence that somewhere around 80% of these kids will eventually become symptomatic, and in order to avoid, particularly a missed symptom, we tend to untether them upfront.
quote · Anorectal Malformation
▶ Ep 121 · 15:54
If you have any, any dysfunction, weakness, numbness. You know, prolonged pain and bladder dysfunction for a long period of time, you're probably not gonna get that back. You may prevent it from worsening, but you're probably not gonna get it back.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 121 · 19:05
If we took all of our tethered cord kids who have anything more than a sectioning of a phylum, and even those kids, and you re-image them, essentially all of them look like they're tethered. But not that many of them are clinically tethered.
quote · Colorectal / ARM & Hirschsprung

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John's statements about Anorectal Malformation 56 statements

Open the Anorectal Malformation collection →

Colorectal Quiz Episode 30: Tethered Cord

▶ Ep 43 · 1:09
clinical After about 3 or 4, maybe 5 months of age, the lamina get broad enough that the ultrasound wave cannot make it through. ↗
▶ Ep 43 · 1:22
clinical If ultrasound shows the conus in a normal position, no further imaging is needed. ↗
▶ Ep 43 · 1:27
clinical If the conus is clearly low on ultrasound, do not do an MRI right then; refer to neurosurgery and image after 3 months of age when MRI resolution is better and of surgical quality. ↗
▶ Ep 43 · 1:47
clinical The conus medullaris is the very end of the spinal cord; just below it the filum terminale takes off with no further neural tissue, which is why it can be cut. ↗
▶ Ep 43 · 1:47
quote The conus medulais, that is the very, very end of the spinal cord where just below the conus medullarris is where the phylum terminale takes off and there's no further neural tissue, that's why you can cut it. ↗
▶ Ep 43 · 2:06
clinical In a normal person, the spinal cord inside the dura is fairly free and as we grow, the spinal cord goes up with us. ↗
▶ Ep 43 · 2:21
clinical A tethered cord is when the cord is low because during development it has become either attached or fixed in position, and all that tension with growth is felt at the bottom of the cord. ↗
▶ Ep 43 · 2:21
quote So a tethered cord is when the cord is low because during development, it's become either attached or it's become fixed in its position, and of course, all that tension with growth is felt at the bottom of the cord. ↗
▶ Ep 43 · 2:40
clinical The spinal cord is attached to the dura by little dentate ligaments, so all tension from tethering is at the bottom of the cord where nerve roots to lower extremities and bowel/bladder exit. ↗
▶ Ep 43 · 2:53
clinical Tethering causes the cord to become so taut that little micro vessels, particularly arterioles at the end of the cord, get occluded or stenosed, leading to local ischemia; lower sacral nerve roots to bowel and bladder are super sensitive to this ischemia. ↗
▶ Ep 43 · 2:53
quote The reason we think that happens incidentally is because it gets so taut, it gets so Distorted from being pulled on that the little micro vessels, particularly the little arterials in the end of the cord, get occluded and, or at least get stenosed, and there is local ischemia and an ischemic cord leads to nonfunctioning nerve roots, particularly the lower sacral nerve roots which go to the bowel and bladder are super sensitive to this. ↗
▶ Ep 43 · 3:30
clinical When the conus is at the L2-3 disc or upper part of L3 on ultrasound, it is difficult to interpret because the conus does not find its final resting spot until about 4 months of age. ↗
▶ Ep 43 · 3:37
quote You know, the conus doesn't find its final resting spot until about 4 months of age. ↗
▶ Ep 43 · 3:41
clinical If ultrasound at 1 month shows conus at mid-L3, it may go up to a normal level; repeat ultrasound at 3-4 months rather than rushing to MRI. ↗
▶ Ep 43 · 3:58
clinical If repeat ultrasound still suggests tethering, obtain an MRI; barring symptoms, follow the child, but if symptoms develop, consider untethering. ↗
▶ Ep 43 · 4:47
clinical It is very hard, almost impossible, to pick up subtle neurologic issues in a baby; symptoms may not be known until the child gets up on their feet. ↗
▶ Ep 43 · 4:56
clinical Orthopedic manifestations of tethered cord may include one leg shorter than the other, one foot smaller, not moving one leg, or hip dislocation. ↗
▶ Ep 43 · 5:14
clinical In a non-walking infant, tethered cord may present with asymmetric reflexes or asymmetric movement; in a toddler, delayed walking due to asymmetry in lower extremity function is concerning. ↗
▶ Ep 43 · 5:34
quote You know, kids shouldn't complain of back pain, but if you have a 4 year old who complains of back pain, that's concerning. ↗
▶ Ep 43 · 5:34
clinical Children should not complain of back pain; a 4-year-old with back pain is concerning for tethered cord. ↗
▶ Ep 43 · 6:17
clinical Midline cutaneous abnormalities above the gluteal cleft—such as a small meningocele, midline dimple, residual tail, midline lipoma with appendage, or large hemangioma—are classic signs of tethered cord that do not require MRI for diagnosis, though MRI reveals the anatomy and structure. ↗
▶ Ep 43 · 6:46
quote I didn't, I didn't need an MRI to tell me that these kids had tethered cords. The MRI tells us, um, tells me the, the anatomy and the structure, but I knew they had tethered cords. ↗
▶ Ep 43 · 7:06
clinical Dimples within the gluteal cleft (sacral dimples) seldom indicate tethered cord; most are very low coccygeal dimples with tracts going caudal toward the tip of the coccyx, not rostral toward the cord, and show no cord tethering on imaging. ↗
▶ Ep 43 · 9:02
clinical A normal spinal cord should end between T12-L1 and L2-L3 disc spaces; a cord ending at L4-L5 disc space is way too low and clearly tethered. ↗
▶ Ep 43 · 9:05
quote So the very top two arrows are pointing at the disc between T12 and L1, the first bone in lumbar spine, and the next arrow points at the disc between L2 and L3. Or that's sort of the limits to which the normal cord should be. ↗
▶ Ep 43 · 9:20
quote This girl, if you follow the spinal cord down as it tapers off to the third arrow, that's where her cord ends, between L4 and L5 at the L4-5 disc space. That is like way too low. ↗
▶ Ep 43 · 9:46
quote You should not have fat inside the spinal canal. That's not normal. ↗
▶ Ep 43 · 9:46
clinical Fat should not be present inside the spinal canal; while not necessarily bad and present in some normal children, children with tethered cords have a higher incidence of fat in the filum. ↗
▶ Ep 43 · 9:53
quote There are normal people, normal children, normal spinal cords with fat in the phylum. That doesn't necessarily denote a tethered cord. But children who have tethered cords have a higher incidence of having fat in the phylum. ↗
▶ Ep 43 · 10:13
quote It looks like somebody's tugging on it, almost like a rubber band. ↗
▶ Ep 43 · 10:35
clinical In some tethered cord cases, the actual problem is that the filum is thick, non-flexible, and noncompliant, preventing it from stretching; the surgery for this is fairly straightforward. ↗
▶ Ep 43 · 10:35
quote The problem is that the phylum is not stretching. It's thick. It's non-flexible. It's very noncompliant, and because of that, the surgery for this is actually fairly straightforward. ↗
▶ Ep 43 · 10:58
clinical Some children with anorectal malformations and tethered cords have a spinal cord lipoma (lipomyelomeningocele) attached to the dura or extending through the fascia to the skin. ↗
▶ Ep 43 · 13:36
clinical The tendency is to untether babies with tethered cords upfront because evidence shows somewhere around 80% will eventually become symptomatic, and early surgery helps avoid missed symptoms. ↗
▶ Ep 43 · 13:36
quote So that's our tendency is to untether them, untether them when they're babies, because there's evidence that somewhere around 80% of these kids will eventually become symptomatic, and in order to avoid, particularly a missed symptom, we tend to untether them upfront. ↗
▶ Ep 43 · 14:15
quote So unless they're below the 2-3 disc, mid L3 or lower, I don't consider them tethered radiographically. ↗
▶ Ep 43 · 14:15
clinical Unless the conus is below the L2-3 disc (mid-L3 or lower), it is not considered radiographically tethered. ↗
▶ Ep 43 · 14:35
clinical If the conus is at L2-3 disc space, untethering will not be performed regardless of clinical concerns; if below the upper end plate of L3 with any concerning findings, the family should be strongly counseled to consider untethering. ↗
▶ Ep 43 · 14:35
quote To detether, like I tell you, if it's, if it's, if it's at L23, I won't do it, regardless of what you tell me. But I would say that if it is below the L23 disk space, if it's below the upper end plate of L3. Anything that you tell me that's of concern, I would push the family to say, listen, you really need to consider untethering him. ↗
▶ Ep 43 · 15:18
clinical It is very hard to parse out whether bladder dysfunction after an operation is due to the tethered cord or to surgical injury, since both can cause the same problem. ↗
▶ Ep 43 · 15:35
clinical In a little baby with urodynamic studies concerning for a real neurogenic problem and a tethered cord, filum sectioning is a 45-minute operation with relative risks close to zero and potential benefits that are huge. ↗
▶ Ep 43 · 15:54
quote If you have any, any dysfunction, weakness, numbness. You know, prolonged pain and bladder dysfunction for a long period of time, you're probably not gonna get that back. You may prevent it from worsening, but you're probably not gonna get it back. ↗
▶ Ep 43 · 15:54
clinical If there is any dysfunction, weakness, numbness, prolonged pain, or bladder dysfunction for a long period of time, you are probably not going to get that back with surgery; you may prevent it from worsening, but you are probably not going to reverse it. ↗
▶ Ep 43 · 17:41
clinical Blood and infection in tethered cord operations increase the risk for retethering by causing inflammatory processes that allow nerve roots to clump and the cord to potentially retether. ↗
▶ Ep 43 · 17:41
quote Blood in these operations, and God forbid an infection are the two things that will increase your risk for retethering. They cause inflammatory processes which allow the nerve roots to clump and the cord to potentially retether. ↗
▶ Ep 43 · 17:57
clinical The incidence of retethering from sectioning a filum is exceedingly low. ↗
▶ Ep 43 · 17:57
quote The incidence of retethering from. Sectioning a phylum is exceedingly low. ↗
▶ Ep 43 · 18:04
clinical The filum sectioning operation can now be done through a small incision without a complete laminectomy, taking a little bit of one lamina and the one below, opening a door about 1 centimeter, and using a microscope for visualization. ↗
▶ Ep 43 · 18:25
clinical With filum sectioning, there are just two raw ends of a very small (3-4 millimeter) filum; the chances those will come back together is essentially zero, and the chances the end attached to the spinal cord will get stuck somewhere are pretty small. ↗
▶ Ep 43 · 18:37
clinical Children with big lipomas on the end of their cords will have some residual lipoma after untethering; taking out the entire lipoma is not necessary nor safe because you would end up in the cord. ↗
▶ Ep 43 · 18:45
quote Taking out the entire lipoma is not necessary, nor is it safe, because ultimately you're end up in the cord. ↗
▶ Ep 43 · 18:51
clinical Children with lipomas have a much bigger surface area of scar typically on the dorsal aspect of the spine; because children lie on their back and sleep, the cord falls back against the dura and eventually retethers. ↗
▶ Ep 43 · 19:05
quote If we took all of our tethered cord kids who have anything more than a sectioning of a phylum, and even those kids, and you re-image them, essentially all of them look like they're tethered. But not that many of them are clinically tethered. ↗
▶ Ep 43 · 19:05
clinical If all tethered cord patients with anything more than filum sectioning (and even those) are re-imaged, essentially all look like they are tethered, but not that many are clinically tethered. ↗
▶ Ep 43 · 19:18
quote I usually quote for complex tethered cords, 40% retethering clinically, it's probably somewhere between 20% and 40% for a phylum, sectioning, pretty close to zero. ↗
▶ Ep 43 · 19:18
clinical For complex tethered cords, the retethering rate is quoted at 40% clinically, probably somewhere between 20-40%; for filum sectioning, retethering is pretty close to zero. ↗
John's statements about Colorectal / ARM & Hirschsprung 56 statements

Open the Colorectal / ARM & Hirschsprung collection →

Colorectal Quiz Episode 30: Tethered Cord

▶ Ep 121 · 1:09
clinical After about 3 or 4, maybe 5 months of age, the lamina get broad enough that the ultrasound wave cannot make it through. ↗
▶ Ep 121 · 1:22
clinical If ultrasound shows the conus in a normal position, no further imaging is needed. ↗
▶ Ep 121 · 1:27
clinical If the conus is clearly low on ultrasound, do not do an MRI right then; refer to neurosurgery and image after 3 months of age when MRI resolution is better and of surgical quality. ↗
▶ Ep 121 · 1:47
clinical The conus medullaris is the very end of the spinal cord; just below it the filum terminale takes off with no further neural tissue, which is why it can be cut. ↗
▶ Ep 121 · 1:47
quote The conus medulais, that is the very, very end of the spinal cord where just below the conus medullarris is where the phylum terminale takes off and there's no further neural tissue, that's why you can cut it. ↗
▶ Ep 121 · 2:06
clinical In a normal person, the spinal cord inside the dura is fairly free and as we grow, the spinal cord goes up with us. ↗
▶ Ep 121 · 2:21
clinical A tethered cord is when the cord is low because during development it has become either attached or fixed in position, and all that tension with growth is felt at the bottom of the cord. ↗
▶ Ep 121 · 2:21
quote So a tethered cord is when the cord is low because during development, it's become either attached or it's become fixed in its position, and of course, all that tension with growth is felt at the bottom of the cord. ↗
▶ Ep 121 · 2:40
clinical The spinal cord is attached to the dura by little dentate ligaments, so all tension from tethering is at the bottom of the cord where nerve roots to lower extremities and bowel/bladder exit. ↗
▶ Ep 121 · 2:53
quote The reason we think that happens incidentally is because it gets so taut, it gets so Distorted from being pulled on that the little micro vessels, particularly the little arterials in the end of the cord, get occluded and, or at least get stenosed, and there is local ischemia and an ischemic cord leads to nonfunctioning nerve roots, particularly the lower sacral nerve roots which go to the bowel and bladder are super sensitive to this. ↗
▶ Ep 121 · 2:53
clinical Tethering causes the cord to become so taut that little micro vessels, particularly arterioles at the end of the cord, get occluded or stenosed, leading to local ischemia; lower sacral nerve roots to bowel and bladder are super sensitive to this ischemia. ↗
▶ Ep 121 · 3:30
clinical When the conus is at the L2-3 disc or upper part of L3 on ultrasound, it is difficult to interpret because the conus does not find its final resting spot until about 4 months of age. ↗
▶ Ep 121 · 3:37
quote You know, the conus doesn't find its final resting spot until about 4 months of age. ↗
▶ Ep 121 · 3:41
clinical If ultrasound at 1 month shows conus at mid-L3, it may go up to a normal level; repeat ultrasound at 3-4 months rather than rushing to MRI. ↗
▶ Ep 121 · 3:58
clinical If repeat ultrasound still suggests tethering, obtain an MRI; barring symptoms, follow the child, but if symptoms develop, consider untethering. ↗
▶ Ep 121 · 4:47
clinical It is very hard, almost impossible, to pick up subtle neurologic issues in a baby; symptoms may not be known until the child gets up on their feet. ↗
▶ Ep 121 · 4:56
clinical Orthopedic manifestations of tethered cord may include one leg shorter than the other, one foot smaller, not moving one leg, or hip dislocation. ↗
▶ Ep 121 · 5:14
clinical In a non-walking infant, tethered cord may present with asymmetric reflexes or asymmetric movement; in a toddler, delayed walking due to asymmetry in lower extremity function is concerning. ↗
▶ Ep 121 · 5:34
quote You know, kids shouldn't complain of back pain, but if you have a 4 year old who complains of back pain, that's concerning. ↗
▶ Ep 121 · 5:34
clinical Children should not complain of back pain; a 4-year-old with back pain is concerning for tethered cord. ↗
▶ Ep 121 · 6:17
clinical Midline cutaneous abnormalities above the gluteal cleft—such as a small meningocele, midline dimple, residual tail, midline lipoma with appendage, or large hemangioma—are classic signs of tethered cord that do not require MRI for diagnosis, though MRI reveals the anatomy and structure. ↗
▶ Ep 121 · 6:46
quote I didn't, I didn't need an MRI to tell me that these kids had tethered cords. The MRI tells us, um, tells me the, the anatomy and the structure, but I knew they had tethered cords. ↗
▶ Ep 121 · 7:06
clinical Dimples within the gluteal cleft (sacral dimples) seldom indicate tethered cord; most are very low coccygeal dimples with tracts going caudal toward the tip of the coccyx, not rostral toward the cord, and show no cord tethering on imaging. ↗
▶ Ep 121 · 9:02
clinical A normal spinal cord should end between T12-L1 and L2-L3 disc spaces; a cord ending at L4-L5 disc space is way too low and clearly tethered. ↗
▶ Ep 121 · 9:05
quote So the very top two arrows are pointing at the disc between T12 and L1, the first bone in lumbar spine, and the next arrow points at the disc between L2 and L3. Or that's sort of the limits to which the normal cord should be. ↗
▶ Ep 121 · 9:20
quote This girl, if you follow the spinal cord down as it tapers off to the third arrow, that's where her cord ends, between L4 and L5 at the L4-5 disc space. That is like way too low. ↗
▶ Ep 121 · 9:46
clinical Fat should not be present inside the spinal canal; while not necessarily bad and present in some normal children, children with tethered cords have a higher incidence of fat in the filum. ↗
▶ Ep 121 · 9:46
quote You should not have fat inside the spinal canal. That's not normal. ↗
▶ Ep 121 · 9:53
quote There are normal people, normal children, normal spinal cords with fat in the phylum. That doesn't necessarily denote a tethered cord. But children who have tethered cords have a higher incidence of having fat in the phylum. ↗
▶ Ep 121 · 10:13
quote It looks like somebody's tugging on it, almost like a rubber band. ↗
▶ Ep 121 · 10:35
quote The problem is that the phylum is not stretching. It's thick. It's non-flexible. It's very noncompliant, and because of that, the surgery for this is actually fairly straightforward. ↗
▶ Ep 121 · 10:35
clinical In some tethered cord cases, the actual problem is that the filum is thick, non-flexible, and noncompliant, preventing it from stretching; the surgery for this is fairly straightforward. ↗
▶ Ep 121 · 10:58
clinical Some children with anorectal malformations and tethered cords have a spinal cord lipoma (lipomyelomeningocele) attached to the dura or extending through the fascia to the skin. ↗
▶ Ep 121 · 13:36
quote So that's our tendency is to untether them, untether them when they're babies, because there's evidence that somewhere around 80% of these kids will eventually become symptomatic, and in order to avoid, particularly a missed symptom, we tend to untether them upfront. ↗
▶ Ep 121 · 13:36
clinical The tendency is to untether babies with tethered cords upfront because evidence shows somewhere around 80% will eventually become symptomatic, and early surgery helps avoid missed symptoms. ↗
▶ Ep 121 · 14:15
quote So unless they're below the 2-3 disc, mid L3 or lower, I don't consider them tethered radiographically. ↗
▶ Ep 121 · 14:15
clinical Unless the conus is below the L2-3 disc (mid-L3 or lower), it is not considered radiographically tethered. ↗
▶ Ep 121 · 14:35
quote To detether, like I tell you, if it's, if it's, if it's at L23, I won't do it, regardless of what you tell me. But I would say that if it is below the L23 disk space, if it's below the upper end plate of L3. Anything that you tell me that's of concern, I would push the family to say, listen, you really need to consider untethering him. ↗
▶ Ep 121 · 14:35
clinical If the conus is at L2-3 disc space, untethering will not be performed regardless of clinical concerns; if below the upper end plate of L3 with any concerning findings, the family should be strongly counseled to consider untethering. ↗
▶ Ep 121 · 15:18
clinical It is very hard to parse out whether bladder dysfunction after an operation is due to the tethered cord or to surgical injury, since both can cause the same problem. ↗
▶ Ep 121 · 15:35
clinical In a little baby with urodynamic studies concerning for a real neurogenic problem and a tethered cord, filum sectioning is a 45-minute operation with relative risks close to zero and potential benefits that are huge. ↗
▶ Ep 121 · 15:54
quote If you have any, any dysfunction, weakness, numbness. You know, prolonged pain and bladder dysfunction for a long period of time, you're probably not gonna get that back. You may prevent it from worsening, but you're probably not gonna get it back. ↗
▶ Ep 121 · 15:54
clinical If there is any dysfunction, weakness, numbness, prolonged pain, or bladder dysfunction for a long period of time, you are probably not going to get that back with surgery; you may prevent it from worsening, but you are probably not going to reverse it. ↗
▶ Ep 121 · 17:41
quote Blood in these operations, and God forbid an infection are the two things that will increase your risk for retethering. They cause inflammatory processes which allow the nerve roots to clump and the cord to potentially retether. ↗
▶ Ep 121 · 17:41
clinical Blood and infection in tethered cord operations increase the risk for retethering by causing inflammatory processes that allow nerve roots to clump and the cord to potentially retether. ↗
▶ Ep 121 · 17:57
quote The incidence of retethering from. Sectioning a phylum is exceedingly low. ↗
▶ Ep 121 · 17:57
clinical The incidence of retethering from sectioning a filum is exceedingly low. ↗
▶ Ep 121 · 18:04
clinical The filum sectioning operation can now be done through a small incision without a complete laminectomy, taking a little bit of one lamina and the one below, opening a door about 1 centimeter, and using a microscope for visualization. ↗
▶ Ep 121 · 18:25
clinical With filum sectioning, there are just two raw ends of a very small (3-4 millimeter) filum; the chances those will come back together is essentially zero, and the chances the end attached to the spinal cord will get stuck somewhere are pretty small. ↗
▶ Ep 121 · 18:37
clinical Children with big lipomas on the end of their cords will have some residual lipoma after untethering; taking out the entire lipoma is not necessary nor safe because you would end up in the cord. ↗
▶ Ep 121 · 18:45
quote Taking out the entire lipoma is not necessary, nor is it safe, because ultimately you're end up in the cord. ↗
▶ Ep 121 · 18:51
clinical Children with lipomas have a much bigger surface area of scar typically on the dorsal aspect of the spine; because children lie on their back and sleep, the cord falls back against the dura and eventually retethers. ↗
▶ Ep 121 · 19:05
clinical If all tethered cord patients with anything more than filum sectioning (and even those) are re-imaged, essentially all look like they are tethered, but not that many are clinically tethered. ↗
▶ Ep 121 · 19:05
quote If we took all of our tethered cord kids who have anything more than a sectioning of a phylum, and even those kids, and you re-image them, essentially all of them look like they're tethered. But not that many of them are clinically tethered. ↗
▶ Ep 121 · 19:18
quote I usually quote for complex tethered cords, 40% retethering clinically, it's probably somewhere between 20% and 40% for a phylum, sectioning, pretty close to zero. ↗
▶ Ep 121 · 19:18
clinical For complex tethered cords, the retethering rate is quoted at 40% clinically, probably somewhere between 20-40%; for filum sectioning, retethering is pretty close to zero. ↗